Today’s Dietitian
Vol. 27 No. 9 P. 20
It’s estimated that 54 million Americans have osteopenia (low bone density) or osteoporosis, a systemic skeletal disease that is characterized by increased bone turnover and low bone mass, leading to structural deterioration of bone tissue, bone fragility, and increased risk of fracture.1,2 This accounts for 54% of Americans over age 50.3
There are numerous dietary and lifestyle strategies for supporting the development of peak bone mass in the primary bone-building years of adolescence,4,5 and preventing or slowing bone loss in various stages of adulthood. But while practices used to protect bone and prevent osteoporosis may also have roles as treatment adjuncts, there comes a point where nutrition and exercise are not sufficient to protect bone quantity and quality and prevent fractures. With the growing food as medicine movement and increased suspicion of science and pharmaceuticals, it’s important for dietitians to know the limits of nutrition and lifestyle so they can support their patients and clients who may be dealing with bone loss, or at risk for it.
Current Dietary Recommendations
It’s well established that calcium and vitamin D are two key nutrients for bone health, but other nutrition recommendations may come as a surprise to some patients and clients. Val Schonberg, RD, MSCP, an Atlanta-based specialist in midlife nutrition and eating disorders, points out that consuming adequate calories is also crucial, as is consuming adequate protein, because that’s part of the collagen matrix that provides structural integrity and strength to bone. Other vitamins and minerals that contribute to bone health, such as magnesium and vitamin K, are also important.
“If we have a food first approach, we’re doing all those things,” she says. “And then there’s that next level of lifestyle, which is weight-bearing activity. Theoretically, if you have mechanical resistance on the bone, it has to adjust and it’s stronger because of that. And then we look at all the other things—such as not smoking—on the list of modifiable and the nonmodifiable risk factors.”6
But are nutrition and lifestyle recommendations for building bone and preventing bone loss also effective for treating bone loss? In the increasingly vocal menopause influencer space, this is what many people—including some health care providers—are saying or at least implying. Given that women make up 80% of osteoporosis cases and an estimated additional 27.3 million women have osteopenia, there is a broad audience for this misinformation.7
What I’ve seen happen, especially with people who are a little bit older and get a diagnosis of low bone density, osteopenia or even osteoporosis, is people start to say, ‘Well, before you go on medication, you should go lift heavy weights, make sure you’re eating enough protein.’” Schonberg says. “And they don’t even give a lot of credit to calcium and vitamin D. And that’s really unfortunate.”
Bone “Bank Accounts”
Low bone density is a concern primarily because it’s a strong risk factor for a more serious health endpoint—a bone fracture. However, many individuals who experience a fracture have normal or modestly reduced bone mineral density. Because of this, bone health screening has become more focused on calculating an individual’s absolute fracture risk, with bone mineral density viewed more as a risk factor than as a condition to be treated.8
Adequate nutrition and physical activity—especially in the first 20 years of life—help an individual build what Julie Carkin, MD, medical director of the Osteoporosis and Strong Bones Program at the University of Washington Medical Center in Seattle, calls their “bone bank account.” But healthy behaviors are not a guarantee of healthy bones. “You can be someone who’s been incredibly healthy and you’re doing all the right things, and it’s not always possible to know what your bone bank account is,” Carkin says.
She points to factors that can contribute to early or unusually high withdrawals. For example, a patient who has always been diligent about nutrition and physical activity may have been undereating or maintaining a low body weight, which increases the risk of low bone density. Patients with a history of a restrictive eating disorder are at increased risk, as are elite and recreational athletes who have a history of underfueling.9,10
Carkin notes that certain health conditions and medications can also compromise bone density. Celiac disease is one example. “Somebody could feel completely healthy, they’re eating well, they’re telling you they’ve been on their gluten-free diet, but they may have had malabsorption at different times when they weren’t gluten-free,” she says. Patients with long-term or high-dose use of corticosteroid medications—perhaps to reduce inflammation in conditions such as asthma, allergies, rheumatoid arthritis, and inflammatory bowel disease—are also at increased risk of low bone density, because these medications reduce the body’s ability to absorb calcium, increase bone turnover, and increase fracture risk regardless of bone mineral density.11,12
Hormone-focused therapy used for treatment of breast or prostate cancer, as well as for treatment of endometriosis and uterine fibroids, may significantly reduce levels of estrogen and testosterone in the body, promoting accelerated bone loss.12 Similarly, women who go through premature menopause regardless of cause are at increased risk of bone loss.
Screening and Diagnosis
The American Association of Clinical Endocrinology (AACE) and the American College of Endocrinology (ACE)13 recommend that all postmenopausal women aged 50 or older be evaluated for osteoporosis risk with a detailed history, physical exam, and clinical fracture risk assessment with a fracture risk calculator such as FRAX.14 Based on an individual’s fracture risk profile, their doctor may recommend measuring their bone mineral density with dual-energy X-ray absorptiometry (DXA) scans of the lumbar spine and hip, which Carkin points out is noninvasive, low-radiation, and low-risk.
DXA uses radiation to measure how much calcium and other minerals are in a specific area of bone. For postmenopausal women and men aged 50 or older, it provides a T-score, which is the difference between the tested individual’s bone mineral density and that of a healthy young adult. A T-score of -1 or higher indicates healthy bone, a score between -1 and -2.5 indicates osteopenia, and a score of -2.5 or lower suggests osteoporosis. Children, premenopausal women, and men younger than 50 get Z-scores. A Z-score of -2.0 or less means bone mineral density is low.15
The Bone Health & Osteoporosis Foundation (BHOF) recommends that all women over 65 should have a bone density test, even if risk calculators suggest they aren’t at high risk of fracture.16 Calkin agrees. “It’s really helpful to know,” she says. “You wouldn’t head into retirement and have no idea how much your nest egg is.” For women and men who have personal or family risk factors for fracture, testing is recommended as early as age 50.
Most expert groups—including the BHOF, the Endocrine Society, and the American College of Preventive Medicine—recommend that men aged 70 or older receive bone density testing, with The Canadian Osteoporosis Society recommending testing for men over 65. “Most men that have been healthy have a higher bank account to start off with. But by the time men are 70, about 75% of men are either in the osteopenia or osteoporosis category. And if men fracture, they do worse. The mortality after a hip fracture for men is higher.”
Carkin says a patient’s current fracture risk needs to be considered in tandem with whether they are experiencing something that’s likely to accelerate bone loss. “For example, someone newly in menopause might be young and healthy, but the estrogen deficiency of the next five years will put them into a high bone turnover state,” she says. “If they have a marginal bank account coming into something that is going to make them lose bone density, they should at least have a conversation with their doctor about, ‘Hey, how could I protect that bone bank account?’ It doesn’t mean they have to be on a medication forever.”
Carkin says there’s strong data demonstrating that a parental history of a hip fracture is an indicator of increased risk,17 and that a previous low-trauma fracture, also known as a fragility fracture, is another significant risk factor. “If a healthy person says, ‘I was on my boat and it was slippery and I fell and broke my wrist,’ that’s a huge red flag because with that same fall, not everybody would have fractured,” she says. AACE/ACE guidelines say that when a patient with normal bone mineral density sustains a fracture without major trauma, consider referral to a clinical endocrinologist or other osteoporosis specialist, because osteoporosis is diagnosed based on presence of fragility fractures in the absence of other metabolic bone disorders and even with a normal bone mineral density.13
Exploring Assumptions About Treatment
Having a correct diagnosis is important, because that may signal that a patient needs to shift out of prevention mode and into treatment mode. Even though dietitians don’t prescribe medications, they can play a role in treatment by providing adjunct nutrition and lifestyle care and encouraging appropriate medical consultations.
“For dietitians, our role is to help people feel confident about their lifestyle choices and how to implement them in their own life, given their scenario, and kind of stay out of the pharmacological part,” Schonberg says. “No matter whether you agree or disagree or what your lived experience is, your job is to refer to an endocrinologist who is going to decide what medication that person needs to be taking and then work with the rest of the treatment team to be the nutrition person. And then that’s when doctors rely more on dietitians. Because when we stay in our lane and do our work, we’re supporting their work.”
Carkin says dietitians can help their patients and clients look at the big picture of how diet and exercise play a role, but also the contributions of genes, past health and gastrointestinal function, and the other factors that contribute to the bone bank account. They can also encourage patients to look at their fracture risks and current medical status with their doctor so they can explore their options and see what fits.
“The goal of treatment is that you don’t treat people just because they have kind of a lowish bone bank account. You treat people because they have a high short or long-term risk of fracture,” Carkin says. When someone has had a DXA scan, they can plug that into the FRAX along with other risk factors to learn their risk of having an osteoporotic fracture in the next 10 years. “If your fracture risk is low, great. See what you can do with your diet and your exercise and decide together with your doctor when to get a new bone density scan. It doesn’t mean you’re not going to recheck that bone bank account, but you may not need to use a pharmacologic intervention.” If a patient does have a high risk of fracture, they can still use those healthy behaviors that they hoped would be “enough” as tools that will support pharmacological therapy.
The AACE/ACE clinical guidelines strongly recommend pharmacologic therapy for patients with osteoporosis, and with osteopenia and a history of fragility fracture of the hip or spine or a high risk of osteoporotic fracture in the next 10 years. They also recommend considering pharmacological therapy for several other type of patients, including those with multiple fractures or fractures while on drugs causing skeletal harm, such as long-term glucocorticoids.13 The Endocrine Society recommends pharmacologically treating postmenopausal women at high risk of fractures, especially those who have experienced a recent fracture, as the benefits outweigh the risks.18
Carkin says it’s a misconception that starting pharmacological therapy means continuing it forever. “They may be surprised. The options can be pretty minimal.” She points to a study from earlier this year in the New England Journal of Medicine that randomly assigned postmenopausal women aged 50 to 60 with T-scores less than 0 but higher than -2.5 to receive either two 5-mg infusions of zoledronate at baseline and year five, one dose at baseline with a placebo at year five, or placebos at baseline and year five. The women receiving both doses of zolendronate were 30% less likely to experience any fracture—and 40% less likely to experience an osteoporotic fracture—in the 10 years of follow up compared with the placebo-placebo group. Interestingly, the women who received one zolendronate dose at baseline saw a 23% reduced risk of any fracture and a 29% decreased risk of osteoporotic fractures compared with placebo.19
This is an example, Carkin says, of a simple, targeted, short-term intervention during a time when bones would be in a high turnover state. She said similar interventions could be appropriate for people on steroids. “They can protect their bones until their pulmonologist or the GI doctor or the rheumatologist gets their primary disease under control and gets them off steroids.”
With all the talk about bone density (quantity), the bone’s structure (quality) is often overlooked, Carkin says. Even though when density decreases, so does the structure. She describes the bone’s structure as a honeycomblike scaffolding, and when bone density decreases, the connectivity of that scaffolding breaks up, decreasing bone strength. “Now there are fancier bone-forming meds that can get some of that connectivity back. But it’s harder to get that structure back, so if you can prevent losing that structure, all the better. Once you get over whatever it is—the high-dose steroids that you’re needing for your illness or the first five years of menopause—it’s not going to still be melting away.”
Protein and Heavy Lifting
What about those influencer recommendations to eat a high-protein diet and lift heavy weights? “I’m unaware of any evidence that high protein can decrease fracture risk,” Calkin says. “If someone is calcium sufficient, we know higher protein doesn’t cause bone loss and it’s probably helpful, but that’s a very hard study to do; however, we don’t have any strong evidence that it can increase bone density. The bones need enough calories, and they need not just protein, but carbohydrates, fats, and micronutrients.”
Heavy exercise, on the other hand, can increase bone density. “We’ve known that for a while, but we also know that you have to maintain it,” she says, pointing to the LIFTMOR study out of Australia,20 in which participants engaged in supervised high-intensity exercise with heavy weights. “They had about an 8% improvement, but the people who didn’t continue, who went back to doing some yoga, doing some tai chi, just regular stuff, they really weren’t able to maintain it.”
Fortunately, a review by the International Osteoporosis Foundation this year found that even moderate physical activity, together with a reduction in sedentary behavior, can maximize and preserve skeletal health while preventing osteoporotic fractures across the lifespan. And those are habits that dietitians help patients and clients build everyday.21
The Takeaway
While nutrition and lifestyle interventions, including incorporating regular physical activity and consuming adequate calories, macronutrients, and micronutrients—especially in the first 20 years of life as we build up the bone bank account—can play a decisive role in determining lifelong risk for osteoporosis, many factors outside our control may exist that increase risk. Additionally, once risk for bone fracture is assessed and determined to be significant, nutrition alone may not be enough to lower risk. Knowing the limitations of nutrition interventions and treatment, including understanding when to refer to a provider who may prescribe pharmacological intervention, is important. These medications, if used, may not necessarily need to be employed long term or in high doses to see clinically meaningful results. Dietitians can provide impactful nutrition and lifestyle support, offer proper referrals for more thorough risk assessment, and may help manage any relevant drug-nutrition side effects.
— Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Non-Diet Approach to Optimal Well-Being.
References
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14. FRAX Calculation Tool: https://www.fraxplus.org/calculation-tool
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